Ga Flashcards
Define coeliac disease:
It is an autoimmune condition, associated with chronic inflammation of the small intestine
Dietary proteins known as gluten present in wheat, barley rye activates an abnormal immune response in intestinal mucosa, leading to malabsorption
Note: patients with celiac disease are at an increased risk of malabsorption of key nutrients (calcium, vitamin-d)
State the 3 symptoms associated with coeliac disease?
Diarrhea, abdominal pain and bloating
What dietary protein to avoid in patients with celiac disease:
Gluten
State the complications of celiac disease:
Weakening of the bones, osteoporosis
Iron deficiency anaemia
Vitamin b12 and folate deficiency
State the only effective treatment for coeliac disease?
Strict, life-long gluten-free diet
No drug treatment for celiac disease
What is the drug treatment of choice for the confirmed cases of refractory coeliac disease while awaiting specialist advice?
Prednisolone
unlike celiac disease, it is resistant or unresponsive to at least 12 months of treatment with a strict gluten-free diet
State the symptoms of diverticular disease?
Abdominal tenderness
and/or mild intermittent lower abdominal pain
with constipation, diarrhea and occasional rectal bleeds
Symptoms may overlap with other Gl complications
Diverticular disease is a condition where small pouches (diverticula) form in the lining of the digestive system, usually in the colon. These pouches can become inflamed or infected, leading to symptoms like abdominal pain, bloating, constipation, or diarrhea.
Diverticula can form due to weak spots in the colon wall, which can happen because of factors like a low-fiber diet, aging, or genetic predisposition. When there’s not enough fiber in the diet, the colon has to work harder to move stool, which can lead to increased pressure and the formation of diverticula.
What is the treatment of uncomplicated diverticulitis?
Low residue diet and bowel rest
Antibiotics are only given when patients are immunocompromised / signs of infection
A low residue diet is a way of eating that limits foods high in fiber and other indigestible materials. It’s designed to reduce the amount of undigested food passing through the gut, which can help alleviate symptoms like diarrhea, abdominal pain, and bloating.
State symptoms of diverticulosis:
Asymptomatic presence of diverticula (small pouches protruding from walls of large intestine)
Common in patients aged 40 and over
What surgery is required for patients with diffuse peritonitis?
Urgent sigmoid colectomy
State the two-side effects associated with sulfasalazine?
Blood disorders and lupus-like syndrome
State side effects of aminosalicylates:
Common = Cough, dizziness, fever, arthralgia, gastro discomfort, leucopoenia
(reduction of white blood cells = increased risk of infection), nausea, vomiting, skin reactions
Uncommon = alopecia, depression, myalgia, photosensitivity reaction,
thrombocytopenia
Very rare = agranulocytosis, cardiac inflammation, pancreatitis
State patient and carer advice for aminosalicylates:
Report any unexplained bleeding, bruising, purpura, sore throat, fever or malaise
For sulfasalazine = some soft contact lens may be stained
State monitoring requirements for aminosalicylates:
Renal function should be monitored before starting an oral aminosalicylate, at 3 months of treatment and then annually during treatment
Full blood counts (including differential white cell count and platelet count) are necessarily initially, and at monthly intervals during the first 3 months
Liver function test should be performed at monthly intervals for first 3 months
What should be co-prescribed with methotrexate and why?
Folic acid, usually dosage once weekly, why because to avoid methotrexate toxicity
Define Crohn’s disease:
Chronic inflammatory bowel disease mainly affects the Gl tract, thickened area of GI wall with inflammation extending to all layers
State the symptoms of Crohn’s disease?
Abdominal pain, diarrhea, fever, weight loss, rectal bleeding, mouth ulcers, sore eyes, arthritis, fatigue
Crohn’s also a cause of secondary osteoporosis
State the non-drug treatment for Crohn’s disease:
Stop smoking and attention to nutrition
What is the monotherapy treatment of Crohn’s disease?
Prednisolone or methylprednisolone or IV hydrocortisone (to reduce remission / within first 12 months)
Budesonide (distal ileal, ileocecal or right sided colonic disease)
Sulfasalazine /mesalazine
What is the add-on treatment of Crohn’s disease?
Azathioprine or mercaptopurine
Methotrexate
In patients who are deficient to thiopurine methyltransferase what drug can be added to their Crohn’s treatment?
Methotrexate
Specialist treatment of Crohn’s disease?
Adalimumab or infliximab
Vedolizumab
Which two drugs can be used to treat diarrhea associated with Crohn’s disease without colitis?
Loperamide or codeine
Which drug is licensed for relief of diarrhea associated with Crohn’s disease?
Colestyramine
Which is the treatment of fistulating Crohn’s disease?
Metronidazole or/and ciprofloxacin
State some factual information regarding ulcerative colitis:
Common in 15-25 age range
It is life-long
Characterised by diffuse mucosal inflammation, relapse remitting pattern
What ages is ulcerative colitis most common in?
15-25
State the symptoms of ulcerative colitis:
Bloody diarrhea, urgent need to go to toilet, abdominal pain, > 6 weeks of faecal urgency, painful persistent urge to pass stool when rectum is empty
What are the complications associated with ulcerative colitis?
Secondary osteoporosis
Increased risk of colorectal cancer
Toxic megacolon
Venous thromboembolism
How should you manage symptoms of ulcerative colitis:
Diarrhoea - exclude any alternative cause
Do not prescribe loperamide unless advised by specialist as they do not usually reduce stool frequency and can increase the risk of toxic megacolon
Constipation - assess for bowel obstruction, if bowel obstruction is unlikely, ensure that diet includes adequate fluid and soluble fibre, and warn that soluble fibre sometimes increases bloating and distension. If symptoms persist despite dietary advice consider a bulk-forming laxative, such as ispaghula husk, methylcellulose, sterculia
Abdominal pain - persistent or recurrent abdominal pain is common in ulcerative colitis and may be caused by inflammatory exacerbations and poor disease control, obstruction, intestinal dilatation: Give paracetamol for pain relief and avoid NSAIDs
Why is it a risk of using loperamide for relief of diarrhea in patients with ulcerative colitis?
Increases risk of toxic megacolon
State some side effects for aminosalicylates?
Blood disorders, lupus-like syndrome, cough, gastrointestinal discomfort, leucopoenia, skin reactions
State one patient and carer advice for patients taking aminosalicylates?
To report any unexplained bruising, bleeding, purpura, fever, sore throat, malaise (blood disorders)
What is the monitoring requirement for aminosalicylates?
Monitor Renal function before treatment, 3 months and then annually
What do you monitor in breast-fed infants whose mother is taking balsalazide sodium?
Monitor for diarrhea in infant
State common side effects for Sulfasalazine?
Taste altered, urine abnormalities, insomnia, tinnitus, yellow discolouration of bodily fluids
State the monitoring requirements for sulfasalazine?
FBC, white cell count, platelet count initially, and at monthly intervals during first 3 months
LFTs at monthly intervals for first 3 months
What are the monitoring requirements for budesonide when used in autoimmune hepatitis?
LFTs should be done every 2 weeks for 1 month, and then at least every 3 months
What age is IBS common in?
20-30’s and is more common in women
What are the symptoms of IBS?
Abdominal pain, discomfort, diarrhea or constipation, passage of mucus and bloating
State counselling points for patients with IBS?
Increase physical activity, adults should aim to do 30 mins of moderate intensity of physical activity at-least 5 days of the week Advised to eat more regularly
Limit fresh fruit consumption to no more than 3 portions a day
Fluid intake mostly water should be increased to 8 cups a day
Sorbitol should be avoided in patients with diarrhoea
Probiotics can be used for at least 12 weeks
Encourage the patient to identify any associated stress, anxiety and/or depression
If there are predominant symptoms of constipation, advise patient to:
Try soluble fibre supplements for e.g.: ispaghula or food high in soluble fibre i.e., oats and linseed
If there are predominant symptoms of diarrhea and/or bloating advise the patient to:
Reduce intake of insoluble fibre, such as wholemeal or high fibre flour and breads
State the drug treatment for IBS?
Alverine citrate, mebeverine and peppermint oil all OTC medication that can be purchased OTC
Which drug laxative would you avoid in patients with IBS?
Lactulose due to it causing bloating
What can be prescribed if patients who have not responded to laxatives from different classes and who have had constipation for past 12 months for patients with IBS and is also licensed for moderate to severe IBS syndrome associated with constipation?
Linaclotide
State drug treatment for IBS:
Dietary food advice
Bulk forming laxative if constipation persist
Loperamide if diarrhea persist
Mebeverine, alverine or peppermint oil if ongoing symptoms of abdominal pain or spasm
If antispasmodic is ineffective, consider low dose TCA such as amitriptyline (off-label indication)
If TCA is ineffective or not tolerated, consider citalopram or fluoxetine (off-label indication
What are the red flags for constipation?
New onset of constipation especially patients 50+
Anaemia
Abdominal pain
Blood in stool
Weight loss
State the counselling patient for patients with constipation?
Dietary fibre, increase in fluid and exercise advised
Fruits high in fire and sorbitol and fruit juices high in sorbitol can help prevent and treat constipation
Note: laxative abuse may lead to hypokalaemia
How do bulk-forming laxatives work?
Increases the bulk or weight of poo, which in turn stimulates bowel
Onset of action is up-to 72 hours
State four bulk-forming laxatives?
Sterculia, methylcellulose, Bran, Ispaghula husk
How do stimulant laxatives work?
Increases intestinal motility
Give examples of stimulant laxatives?
Bisacodyl, sodium-picosulfate, senna, docusate, co-danthromer
Onset of action is 6-12 hours.
Which laxative acts as a stimulant and faecal softener?
Docusate - docusate can be used as a stimulant and can also soften hard stools
How do faecal softeners work?
Decreases surface tension and increases penetration of intestinal fluid into faecal mass
State 2 side effects for liquid paraffin?
Anal seepage, malabsorption of ADEK fat soluble vitamins, lipoid pneumonia
Excessive use of stimulants can cause what?
Hypokalaemia
State the drugs which colour urine and bodily secretions:
Nefopam = pink
Triamterene = blue
Sulfasalazine = yellow orange
Rifampicin = orange-red
Nitrofurantoin = yellow-brown
Senna = red-yellow
Co-danthramer = red
Co-danthrusate = red
Levodopa = red
B-vitamins = bright yellow
Entacapone = red-brown
What colour does co-danthromer, co-danthrusate discolour urine?
Red - danthron is genotoxic and carcinogenic used in terminally ill patients
Which laxative can only be used in females?
Prucalopride - licensed for treatment of chronic constipation in adults
What is the management of opioid induced constipation?
Stimulant AND osmotic laxative (or docusate to soften stools)
Naloxegol/methylnaltrexone
Note: bulk-forming laxatives should be avoided!
What is the management of chronic constipation?
Bulk forming, whilst ensuring good hydration
If stools remain hard, add or change to an Osmotic laxative e.g., macrogol
Lactulose is an alternative if macrogols are not tolerated
Stimulant can be added to treatment
Prucalopride in women only once at-least 2 laxatives from different classes have been tried at the highest tolerated recommended dose for at-least 6 months
What is the management of constipation in pregnancy?
Fibre supplements in form of bran or wheat
Bulk-forming laxative first choice if fibre supplements fail
Osmotic laxative such as lactulose can be used
Bisacodyl or senna may be suitable if stimulant effect is necessary but senna should be avoided near term of if there is history of unstable pregnancy
Stimulant laxatives are more effective than bulk-forming but are more likely to cause side effects diarrhea and abdominal discomfort
Which laxative do you avoid at near term in pregnancy?
Senna avoid at term as can induce uterine contractions
What is the management of constipation in breastfeeding?
Bulk-forming, if dietary measures fail
Lactulose or macrogol may be used if stools remain hard
Senna / bisacodyl as short course of stimulant laxative
What is the management of constipation in children?
Macrogol Laxative + diet modification/behavioural intervention
Stimulant
Lactulose or docusate faecal stool softener
What are the red flags for diarrhoea?
Unexplained weight loss, rectal bleeding, persistent diarrhea, following course of antibiotics, following foreign abroad travel
State two drugs which have diarrhoea as a side effect?
Metformin and Iron supplements
What is the treatment of diarrhea?
ORS (oral rehydration salts) + appropriate adequate fluid intake
Loperamide (also for traveller’s diarrhoea) (and first line for faecal incontinence)
Which antibiotic is occasionally used for prophylaxis against traveller’s diarrhea?
Rifaximin
Which drug is licensed as an adjunct to rehydration for the symptomatic treatment of uncomplicated acute diarrhea in adults and children 3 months+?
Raecadotril
What is the maximum amount (in mg) of loperamide an adult can take in one day?
16 mg
What are the side effects of loperamide in overdose?
QT prolongation, torsade’s de pointes, cardiac arrest
What should you monitor if a patient has been detected to have consumed large amounts of loperamide?
CNS depression
What is the antidote to loperamide?
Naloxone
What are the symptoms of dyspepsia?
Upper abdominal pain, fullness, early satiety, bloating and nausea
What are the red flags for dyspepsia?
Bleeding, dysphagia, recurrent vomiting, weight loss, blood in stools, new onset dyspepsia in patients 55+ age, significant acute gastrointestinal bleeding, reflux
State the non-drug treatments for dyspepsia:
Lifestyle measures such as healthy eating
Weight loss if obese
Avoid any trigger foods
Eating smaller meals and eating the evening meal 3-4 hours before going to bed
Raising the heads of the bed
Reduce or quit smoking and reducing alcohol consumption
Treatment for un-investigated dyspepsia?
Proton pump inhibitor for 4 weeks
Test for H.pylori infection (test first for patients who are at high risk of h.pylori infection)
What is the treatment for investigated functional dyspepsia?
1) PPI or H2 receptor antagonist for 4 weeks
State which drugs can cause dyspepsia:
Alpha-blockers
Beta-blockers
Bisphosphonates
Calcium channel blockers
Corticosteroids
Nitrates, Nsaids Theophylline’s, TCAs
State a function of simethicone?
Relief of hiccups in palliative care
Anti-relief foaming agent to relieve flatulence
Which PPI do you have to take 30-60 mins before food?
Lansoprazole - key!
What do PPI’s (proton-pump inhibitors) increase the risk of?
Fractures, osteoporosis, gastric cancer, Clostrium difficile, hypomagnesaemia
Very low risk of subacute cutaneous lupus erythematosus
What is the initial treatment of H. Pylori Infection?
No penicillin allergy:
PPI + amoxicillin + clarithromycin/metronidazole
PPI + amoxicillin + clarithromycin/metronidazole (whichever was not used first)
PPI + amoxicillin + tetracycline/levofloxacin
Penicillin allergy:
PPI + clarithromycin + metronidazole
Ppl + bismuth subsalicylate + metronidazole/tetracycline
PPI + metronidazole + levofloxacin
What is the test for H.Pylori?
Urea-C13 breath test is most popular test, stool helicobacter antigen test can also be done
Note: PHE advises that these 2 tests should not be performed within 2 weeks of treatment with a PPI or within 4-week of antibacterial treatment as this can lead to false negatives
Side effects of H2 receptor antagonists?
Headaches, rashes, dizziness, diarrhea, depression, hallucinations, confusion
State the common food allergens?
Soya, wheat, nuts, shellfish, eggs, soy, cow’s milk, tree nuts, fish
State the licensed treatment of food allergy?
Chlorphenamine
State the treatment of food-induced anaphylaxis?
Adrenaline/Epinepherine - know your child and aduit doses!
State what drug is licensed as an adjunct to dietary avoidance in patients with food allergy:
Sodium cromoglicate
State what drug may be offered an adjunct to dietary avoidance in patients with peanut allergy in childhood:
Peanut protein
State the MHRA safety information for hyoscine butylbromide?
Injection can cause serious effects: tachycardia, hypotension, anaphylaxis (more fatal in those with CHD)
What foods to avoid with MAOIs:
Tyramine rich containing foods i.e.:
Strong aged cheeses, cured meats, processed meats, alcohol, marmite, soybeans, pickled fermented foods, caviar, kimchi
What juice interacts with statin and CCB’s:
Grapefruit juice
This specific juice can aid the absorption of iron:
Fresh orange juice
State symptoms of anal fissure:
Tear or ulcer in lining of the anal canal which causes pain on defecation, with or without bright red rectal bleeding and anal spasm
Acute = if present for less than 6 weeks
Chronic = present for 6 weeks or longer
Primary = no clear underlying cause
Secondary = related to constipation, IBD, STI, colorectal cancer
State treatment of anal fissure:
Dietary and lifestyle advice to ensure stools are soft and easy to pass
High fibre diet and increased fluid intake
Good anal hygiene
Paracetamol or ibuprofen for pain relief
For adults with extreme pain on defecation, prescribe lidocaine 5% ointment
or adults who have persisted for 1 week or more without improvement consider a 6-
8-week course of rectal GTN 0.4% ointment
What colour does the following drug colour your uri ne and bodily secretions: nefopam?
pink
What colour does the following drug colour your uri ne and bodily secretions: triamterene
blue
What colour does the following drug colour your uri ne and bodily secretions: sulfasalazine
yellow orange
What colour does the following drug colour your uri ne and bodily secretions: rifampicin
orange- red
What colour does the following drug colour your uri ne and bodily secretions: nitrofuruantoin
yellow- brown
What colour does the following drug colour your uri ne and bodily secretions: senna
red- yellow
What colour does the following drug colour your uri ne and bodily secretions: co- dranthramer
red
What colour does the following drug colour your uri ne and bodily secretions: co- dranthrusate
red
What colour does the following drug colour your uri ne and bodily secretions: levedopa
red
What colour does the following drug colour your uri ne and bodily secretions: b vitamins
bright yellow
What colour does the following drug colour your uri ne and bodily secretions: entacaoine
red- brown
State treatment of diverticulosis:
Specific treatments are not recommended as asymptomatic condition
Bulk-forming laxatives considered for constipation
State treatment of acute uncomplicated diverticulitis:
Co-amoxiclav
Cefalexin AND metronidazole or trimethoprim and metronidazole or ciprofloxacin
What is the treatment of complicated / severe diverticulitis?
Intravenous antibacterial (gram negative organisms / anaerobes) and bowel rest
What is the recommended treatment for symptomatic diverticular disease?
High fibre diet (bulk-forming drugs but evidence is lacking)
Paracetamol for abdominal pain treatment
NSAIDs not advised as may increase risk of diverticular perforation
